ICML 2025 | Key challenges associated with treating CNS lymphomas & advice for community oncologists

I think it’s a great question because I do think it’s a very nuanced and challenging disease to treat. And when I say disease, I mean, it’s a host of diseases. So I think first I alluded to when talking about the different consolidation regimens, it’s all about patient selection. So really understanding your patient and the toxicity profiles and risk factors before making a selection for consolidation regimens and even induction, what you think the patient can tolerate. So one, I think is important to think about patient selection. Two, it’s all about multidisciplinary collaboration, which I think is a blessing and can make things more challenging too. So you really have to collaborate. And so when I’m thinking about these patients who are seen by community oncologists, you may or may not have access to a blood and marrow transplant team. And so I think my recommendation stems from our work looking at different consolidation regimens is if patients are ineligible for transplant. You don’t think your patient’s the right patient for a transplant, or you don’t have access to a transplant. I would really consider using this reduced-dose whole brain radiation as opposed to just non-myeloablative chemotherapy for some of these patients. And then I think finally, another challenge, again, as a radiation oncologist is not debunking the myth of neurotoxicity, because I do think that’s based on years of data showing that these higher doses of whole brain radiation can be neurotoxic, although they can be a great disease control approach. I think the challenge has been really just informing everyone that there’s different doses with different outcomes and different toxicity profiles. So I think that we really need to consider reduced dose as a totally separate approach than standard dose whole brain when we’re talking about consolidation. At Sloan-Kettering, we also combined all of our data. This was published last year in the Red Journal looking at cerebral atrophy over time after different consolidation regimens. And we actually showed that all primary CNS lymphoma patients after induction basically have cerebral atrophy over time compared to the normal population as they age. So we know that they have cerebral atrophy. I think a huge part of this is the high-dose methotrexate. But our main finding was really that that rate of change over time did not differ by consolidation regimen. So it was similar between transplant patients and reduced dose whole brain radiation patients. So yeah, final one I think is a challenge is thinking about neurotoxicity. And I’d like to remind community oncologists to consider reduced dose whole brain radiation as a safe and effective approach for patients.

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